| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,324 |
1,241 |
$51K |
| D1206 |
Topical application of fluoride varnish |
1,591 |
1,499 |
$50K |
| D1120 |
Prophylaxis - child |
586 |
559 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
91 |
52 |
$18K |
| D1110 |
Prophylaxis - adult |
286 |
268 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
262 |
217 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
180 |
145 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
196 |
138 |
$7K |
| D7210 |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth |
20 |
12 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$3K |
| D1351 |
Sealant - per tooth |
50 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
96 |
63 |
$1K |
| D0272 |
Bitewings - two radiographic images |
27 |
26 |
$937.04 |
| D0603 |
|
1,728 |
1,625 |
$0.00 |